Reproductive Health Information And

Reproductive Health Information and

Outreach Needs Assessment Survey

Why should I do this survey and what will you do with the information?

This survey helps to determine community needs for information about reproductive health. Reproductive health includes topics about birth control, pregnancy issues, sexually transmitted disease/infections, family planning, and related information. It has been developed so you can tell us what information you need. The information that you give will be used to better provide accurate, up-to-date information to meet the need and to prioritize outreach to the community.

Is the information I give kept confidential?

Yes! Please DO NOT write your name on this survey. The answers you give will be kept private. No one will know who you are. The questions about your background will onlybe used to describe the type of people who completed the survey.

How much time does it take to complete the survey?

Most average about 10-15 minutes, but please take the time you need to complete the survey.

What do I do when I’m done taking the survey?

Answer the questions as completely as possible then put the completed survey into the large envelope that is labeled “CONFIDENTIAL.” For those who are responding by mail, return the completed survey in the prepaid envelop within the next 7 days.

Instructions for completing the survey:

Answer the questions as completely as possible. If you are not sure how to answer a question, write your comment next to the question.
When finished with the survey, place it in the “CONFIDENTIAL” envelope or for those returning this by mail, use the prepaid envelop and mail within the next 7 days.

Thank You Very Much For Your Input!

These questions ask about the need that you or your partner(s) may have for reproductive health information and how important the information is to your life and health.

Thinking about the past 12 months, did you or your partner(s) have a need for information regarding the following reproductive health topics? Circle “Yes or No.”

Also, how much difference would the information have made on your life or health? Circle one number to describe the impact the information would have had on your life or health.

Reproductive Health Topic / Have you or your partner needed more information? / If “YES”, how important would this information have been to your life or health?
(1 = not important/just curious to 5 = major impact on one’s life or health) / Any Comments
Birth control pills / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Depo-Provera injections / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Ortho-Evra (“patch”) / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
NuvaRing / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Natural Family Planning/Fertility Awareness Method / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Condoms for men / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Condoms for women / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Diaphragm / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Spermicides (contraceptive creams/jelly) / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Birth Control Sponge / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Emergency Contraception / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Intrauterine Device (IUDs) / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Implanon/Nexplanon (hormonal implant) / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Vasectomy (Male sterilization) / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Female Sterilization / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Contraceptive failure / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Breastfeeding and Contraception / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Breastfeeding as a contraceptive method / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Menstrual Cycle issues / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Reproductive Health Topic / Have you or your partner needed more information? / If “YES”, how important would this information have been to your life or health?
(1 = not important/just curious to 5 = major impact on one’s life or health) / Any Comments
Sexual Dysfunction & Viagra information / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Infertility (difficulty getting pregnant) / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Teen Sexual Issues / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Sexually Transmitted Disease/Infections
(circle which ones in the comment section) / Yes or No / 1 2 3 4 5
No impact Some impact Major impact /

Which ones?

Chlamydia Syphilis

Gonorrhea Herpes
Chancroid HIV/AIDS
Urethritis Cervicitis
Genital Warts (HPV)
Pelvic Inflammatory Disease (PID)
OTHER: ______
Treatment of Sexually Transmitted Diseases/Infections / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Pregnancy / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Prenatal Care / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Adoption / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Pregnancy Termination/Abortion / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
Criteria for starting contraceptive use (who can use what method) / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
OTHER: / Yes or No / 1 2 3 4 5
No impact Some impact Major impact
OTHER: / Yes or No / 1 2 3 4 5
No impact Some impact Major impact

What is the most important thing you need to know about preventing a pregnancy, family planning, sexually transmitted disease or infection (STD/STI), or other related reproductive health topic?”

What are other reproductive health, family planning, pregnancy, or STD/STI topics you would like to know more about?

How do you describe the type of reproductive health information that you seek?

Circle all that apply:

Only Facts / Only a Review / In-depth Information / Research / Clinical Information / Administrative / Other:

Where and how do you like to get new, accurate information (from a medical professional, a friend, the internet, a pamphlet, books, attending a class or group session, the library, hospital, health department, colleagues, professional update periodical, other)?

How often do you want or need the information?

Circle one:

Once / Daily / Monthly / Annually / Other:

These questions allow a general description of those who completed the survey.

How old are you? _____ (Write the number of years old)
Are you: Male_____ or Female ______

What is the highest grade you have completed in school?

1 2 3 4 5 6 7 8 / 9 10 11 12 / 13 14 15 16 17+
Grade school / High School / Vocational/Tech/College/Grad School

How would you describe yourself?

Circle one:

Hispanic Origin / Not Hispanic Origin

Circle one or more:

American Indian or Alaska Native / Asian / Black or African-American
Native Hawaiian or Pacific Islander / White or Caucasian / Other (please describe):

Which best describes your marital status?

Circle one:

Married / Widowed / Divorced/Separated / Single, never married / Partner of unmarried couple

How many people live in your household, including yourself and any children?

1 2 3 4 5 6 7 8 9 10 11 or more

How would you describe your current employment status?

Check all that apply:

Employed full-time for wages / College Student
Employed part-time for wages / High School Student
Self-employed / Jr. High Student
Laid off or unemployed / Current Grade:
Retired / Other:
Full-time homemaker

What was your household’s total income before taxes last year? Include all sources for you and those living in your household.

Check one box:

Less than $9,999 / $35,000 to $39,999
$10,000 to $14,999 / $40,000 to $49,999
$15,000 to $19,999 / $50,000 to $59,999
$20,000 to $24,999 / $60,000 to $69,999
$25,000 to $29,999 / $70,000 to $79,999
$30,000 to $34,999 / $80,000 to $99,999
More than $100,000

Comments:

What can reproductive health clinics, departments, or agencies in Colorado do to have a greater impact on the community’s reproductive health? (Please write your answer in the space below)

______

Do you have any comments about this questionnaire or about your reproductive health? We welcome your comments in general or about specific questions, especially any that were unclear or confusing to you.

______

Thank you for completing this questionnaire.

Please return this in the envelope labeled “CONFIDENTIAL” or for those who are responding by mail, return the completed survey in the prepaid envelop within the next 7 days addressed to:

(agency stamp with Attn:______here)

2015 Update